1. I authorize and request my treating provider to carry out
psychological treatment.

2. I acknowledge that I am being informed that under California
law:
a. If a patient communicates to a therapist a serious
threat to harm an identifiable person, the therapist must warn that person
and the police.
b. If the therapist suspects child abuse or neglect,
or abuse of a helpless adult or of an elder, a report must be made to
the designated agency.
c. If a patient seems dangerous to self or others or
unable to care for him/herself, then hospitalization may be required.

3. I understand that:
a. Information and records--otherwise confidential--
concerning me and or my family must be provided in the event of a court order.
b. I understand that Dr. Keller consults professionally
and confidentially with colleagues.

4. My consent is for me and any minor children. Consent
is voluntary and, except for Items 2 and 3 (limits on confidentiality)
and urgent consultations, I may withdraw my consent to future disclosure
at any time by writing a letter to Dr. Keller.

5. I have received a copy of this form.

DatePatientWitness

This consent is in effect for the duration of treatment
up to three years.